Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden.

BACKGROUND: Many patients with previous pulmonary tuberculosis (PTB) continue to experience respiratory symptoms long after completion of tuberculosis (TB) therapy, often resulting in numerous hospital visits and admissions. OBJECTIVES: To describe the profile of patients with chronic lung disease (CLD) with or without a history of PTB, and their in-hospital outcomes. METHODS: We conducted a retrospective review of patients with CLD admitted with respiratory symptoms to Dora Nginza Hospital, Port Elizabeth, South Africa, from 1 April 2016 to 31 October 2016. These patients were divided into two groups: CLD with a history of PTB (CLD-TB) and CLD without a history of PTB. Patients with current culture-positive TB were excluded. Baseline characteristics and clinical outcomes (duration of hospitalisation and in-hospital mortality) were compared between the two groups. RESULTS: During the study period, a total of 4 884 patients were admitted and 242 patients received a diagnosis of CLD. In the CLD patient group, 173 had CLD-TB and 69 had no history of PTB. Patients with CLD-TB presented with respiratory symptoms a median of 41 months (interquartile range (IQR) 101) after completion of TB therapy. CLD-TB patients were predominantly male (59.5%), and compared with patients with no history of PTB were more likely to be HIV-positive (49.7% v. 8.7%; p=0.001) and had had more frequent hospital admissions before the current admission (median 2.0 (IQR 2.0) v. 0; p=0.001) and longer hospital stays (median 5 days (IQR 7) v. 2 (4); p=0.002). However, there was no statistically significant difference in in-hospital mortality between the two groups (17.3% v. 10.1%; p=0.165). CONCLUSIONS: In patients with CLD, a history of PTB is associated with numerous hospital admissions and longer hospital stays but not with increased in-hospital mortality. TB therefore continues to be a public health burden long after cure of active disease.

Evaluation of locally manufactured patient-specific custom made implants for cranial defects using a silicone mould.

BACKGROUND: Cranial vault defects can pose a significant problem for neurosurgeons where autologous bone is no longer available for cranioplasty. Numerous materials exist to create implants which include polymethyl methacrylate (PMMA) and titanium. A technique using 3-dimensional CT scan reconstruction of a cranial defect and creating a silicon mould which can be autoclaved in theatre to create a PMMA implant was developed. OBJECTIVE: The aim of this study is to evaluate the efficacy, cosmetic result, safety and cost-effectiveness of this procedure and compare this to existing techniques. METHOD: An ambispective study was performed in patients requiring cranioplasty with a custom made implant. Patients were assessed for risk factors and cosmetic outcome, surgical technique was described and complications and cost compared to existing literature between 2010 and 2016. RESULTS: Thirty retrospective and 30 consecutive prospective patients were recruited into the study. Overall sepsis rate was 8.3%. All septic cases had superficial sepsis of which 2 grafts were removed due to cerebrospinal fluid leakage resulting in wound breakdown. A 100% accurate implant to defect ratio was achieved leading to a high satisfaction rate. Average cost was 5 times cheaper than the closest market related product. CONCLUSION: Patient specific moulds using PMMA to create custom implants are safe, have excellent cosmetic results and are a very cost-effective option to manage cranial defects. Accurate planning strategies for large craniotomies, where bone will potentially be discarded, add to surgical effectiveness and cost-saving to the patient.

Strategies for Oral Health Research in Africa and the Middle Eastern Region.

The highest burden of diseases worldwide is in low- and middle-income countries, but due to lack of capacity and inadequate infrastructure, research output from these countries is unable to address existing and emerging challenges in health care. Oral health research has particularly been hampered by low prioritization, resulting in insufficient development of this sector. There is an urgent need for research correlating oral health to upstream social and environmental determinants and promoting the common risk factor approach for prevention of noncommunicable diseases. Population-wide preventive measures for oral health care are more effective than purely curative approaches, especially for vulnerable groups who have limited access to information and appropriate health care. This article identifies priorities and proposes strategies for researchers, stakeholders, and policy makers for the initiation and sustenance of appropriate oral health care research. The proposed interventions are intended to promote collaboration, capacity building, and health advocacy. Local ownership in multinational research projects in low- and middle-income countries, complemented by skills transfer from high-income countries, is encouraged to ensure that regional health needs are addressed. Emphasis is placed on a shift toward translational research that has a direct impact on oral health care systems.

Impact of socio-economic factors on quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting.

BACKGROUND: Quality of life (QOL) is an important outcome following the treatment of disease. It is influenced by physical, psychological, social and economic factors. We proposed to determine the effect of some socioeconomic factors on QOL of patients on CAPD. STUDY DESIGN: A cross sectional study in which all patients on CAPD attending three clinics attached to the University of the Witwatersrand, Johannesburg were recruited excluding those with intercurrent illness. The WHO quality of life instrument, WHOQOL-Bref, was used to measure QOL. The patients were grouped according to marital status, highest level of education attained, income, employment, and QOL domain scores were compared using ANOVA and Student t test. RESULTS: A total of 140 patients comprising 80 males and 40 females were assessed. The mean age of patients was 41.9 ± 11.5 years, 95%of patients were black, 44.3% married, 69.3% had secondary education, 22% were employed and 51.4% had a monthly income of less than five thousand Rand (500 US dollars). Single patients scored better in the social relationships domain compared to separated patients (p=0.02, CI: 5.6-32.9). The group with secondary education scored low in the psychological domain compared with those with primary education (p=0.02, CI: 1.35-15.8) and those with tertiary education (p=0.02, CI: 1.72-18.07).The highest income group had best scores in all domains except the physical domain. Those in employment had better scores in the physical domain (p=0.04, CI: 0.356-12.549). CONCLUSION: Income had the most impact on QOL in study participants.

Global oral health inequalities: oral infections-challenges and approaches.

Four oral mucosal infections were identified as Global Oral Health Priorities: (a) HIV and associated viral, bacterial, and fungal infections; (b) tuberculosis; (c) NOMA; and (d) sexually transmitted diseases. Huge global inequalities exist in all four. HIV-associated infections constitute the major challenge. Oral manifestations of AIDS can be specifically diagnostic, indicating a significant role for dentists within health teams. The World Workshops in Oral Health & Disease in AIDS have identified a research program, elements of which are being implemented. Data on oral mucosal involvement in tuberculosis, syphilis, and gonorrhea are incomplete in developed countries and virtually non-existent in low- and middle-income countries, indicating the need for further epidemiological studies. Oral manifestations of tuberculosis and sexually transmitted diseases are largely associated with general health, so action programs should be integrated with agencies treating the systemic diseases. NOMA is very much in the oral health domain. It is a preventable disease associated with malnutrition and unidentified bacterial factors. Prevalence is probably grossly overestimated at present; but nevertheless it constitutes a challenge to the profession, especially in the NOMA belt. Current treatment is surgical, but plans for its eradication should be achievable. The global oral health community, especially the IADR, has a major role to play.

Dental ethics case 6. Stalled payment for ongoing orthodontic treatment--balancing responsibilities.

It is not always easy for an orthodontist to strike the right balance between a caring, supportive and patient-centered approach, and the need to make a living and to run a profitable business in order to achieve this. Striving to act ethically and professionally at all times will help find this elusive balance and ultimately it will be more rewarding and professionally satisfying. Especially when dealing with children whose lives may be dramatically affected by the interruption or cessation of treatment, orthodontists have a duty to reassure themselves about the financial stability of their contractual relationships with patients or parents. Having consistent financial policies and flexible payment options may assist in this regard. Even in the face of non-payment of fees, treatments that have begun must in some form continue if their cessation would compromise the best interests of patients.

Cost implications for the treatment of five oral lesions commonly found in HIV/AIDS.

The objectives of this study were to determine the cost of a prescribed treatment plan; to compare the costs in an academic hospital cost with that of private pharmacy; and to determine the average treatment cost per visit. The descriptive, retrospective study that investigated the cost implications of the treatment of five oral lesions associated with HIV/AIDS: oral candidiasis, oral hairy leukoplakia, periodontal diseases, oral ulcers and Kaposi's sarcoma. One hundred and twenty four cases with oral HIV lesions were selected from the list of 181 HIV patients listed in the attendance registers of three hospitals in the selected study sites. A data capture sheet was used to obtain information related to diagnosis, investigations done, staging of the disease, treatment plan and treatment outcome. None of the patients were on antiretroviral therapy. The association between the number of hospital visits and the total cost of treatment was significant (p < 0.05). Also, there was a significant negative relationship between the outcome of treatment and the total hospital costs (p < 0.05). The lower the hospital treatment cost, the better the outcome. There was no significant association between staging of the disease and the hospital cost (p > 0.05), but the CD4 count significantly influenced the hospital cost (p<0.05). The average hospital treatment and private pharmacy cost was 207.06 and 357.85 rands respectively (16.21 euros and 28.02 euros respectively). There is a need to evaluate the current treatment protocols, as some treatments may be ineffective. Governments should endeavour to provide antiretroviral and other relevant drugs, at no cost, to HIV/AIDS patients.

Access to oral health care and treatment needs of HIV positive paediatric patients / Acesso aos serviços de saúde bucal e necessidade de tratamento de pacientes infantis

Objective: An assessment of the oral manifestations, oral health status and treatment needs of paediatric patients with HIV infection. Method: This is a descriptive study of 55 patients presenting at the special paediatric clinic of the Lagos University Teaching Hospital. A pre-tested questionnaire was used to determine oral health status and treatment needs. Results: Fifty five children made up of 29 (52.7%) males and 26 (47.3%) females were examined. Age range was 6 months to 16 years. Over two-thirds (69.1%) of the children had good oral hygiene. Fourteen (25.5%) had gingivitis. Dental caries was seen in about a third, 17 (30.9%). The most common mucosal lesion was candidiasis. Most of the patient would benefit from oral health counseling. However over a third, 38.2% would require restorative treatment. Conclusion: Paediatric dentists should collaborate with health professionals for effective management of these patients.

Objetivo: Avaliar as manifestações orais, o estado de saúde bucal e as necessidades de tratamento de pacientes infantis com HIV. Método: Trata-se de um estudo descritivo de 55 pacientes atendidos na clínica infantil do Hospital Escola da Universidade de Lagos. Um questionário pré-testado foi utilizado para determinar o status de saúde oral e as necessidades de tratamento. Resultados: Vinte e nove crianças eram meninos (52,7%) e 26 (47,3%) eram meninas. A idade variou de 6 meses a 16 anos. Mais de dois terços [69,1%] das crianças possuíam uma boa higiene oral. Catorze crianças (25,5%) tinham gengivite, enquanto 17 apresentavam lesões de cárie dentária (30,9%). A lesão mais comumente encontrada foi a candidíase. A maioria dos pacientes poderiam se beneficiar de orientação de saúde bucal. Entretanto, mais de um terço, 38,2% necessitavam de tratamento restaurador. Conclusão: Odontopediatras devem contribuir com os demais profissionais de saúde para o efetivo manejo destes pacientes.

Self-perceived and unmet general health need among PLWHA in Nigeria.

OBJECTIVE: This study set out to determine the self-reported unmet health needs of people living with HIV/AIDS (PLWHA) in a Nigerian population. METHODS: A prospective study conducted among consecutive 209 consenting PLWHA in the South-western Nigeria; who sought for care in the Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife and General Hospital, Ilesa were recruited. Participants completed a comprehensive survey seeking information to determine their unmet needs in the following areas: Medication, Dental, Mental, Home care, Hospital admission, access to antiretroviral therapy and emergency services. RESULTS: One or more unmet needs were reported by 79.4% of the sample. Needs for medication, home-based care and mental care were more likely to be unmet. There was a statistically significant relationship between unmet needs and living arrangements (p < 0.05). CONCLUSIONS: Perceived oral health status was the factor that best predicted the unmet need. Perceived oral health status of these patients should be improved to reduce the level of the unmet needs.

Community dental service--four years on.

In July 2000, the first group of graduates entered compulsory community dental service. The aim of this study was to document the experiences of the community dentists four years on. A cross-sectional, descriptive study was carried out among 232 community dentists. A structured questionnaire divided into nine sections: demography, the allocation process, accommodation & living conditions, dental clinic facilities - equipment and materials, work environment, income, sense of achievement, intellectual fulfillment. Forty five per cent of the sample (n = 105) responded, 51% were male and the mean age of the sample was 24.8 years. Of the responadents 47% could speak the local language; nearly a quarter (24%) felt that the allocation process was not handled efficiently and 30% said that they needed more information about their placement posting. Sixty per cent were placed within 20km of the nearest town; 11% did not have access to telephone or fax and 47% were provided with accommodation. Thirty five per cent described the condition of the clinics operating as poor. A fifth of the respondents (21%) indicated that they did not have full sets of instruments. Eight per cent did not have an autoclave and 7% a high-speed hand piece. Fifty one per cent did not have oxygen and nearly two thirds (58%) of the clinics did not have any emergency equipment. Seventy one per cent reported that the equipment broke down often and 65% that it was not fixed promptly. Nearly all (90%) indicated that they would welcome a short course that might assist them to repair broken down equipment. Eighty five per cent reported that they enjoyed their work environment. Seventy per cent had no supervision, but more than a third felt confident enough to work without it. Although 80% felt that their professional competence had improved, an equal number indicated that they have lost some of their clinical competence in one or other area. Despite the fact that 65% reported that there were many opportunities to improve their clinical skills, more than half felt that they were over-skilled for the job. Eighty per cent of the respondents indicated the year was fulfilling and worthwhile. Problem areas centred on the adequacy of the information provided prior to allocation, high cost of accommodation, break down of equipment and lack of basic restorative materials. It is gratifying to note that there have been many improvements since the initial intake of community dentists in 2000, but there remains a few areas that still need to be addressed.

Causes and distribution of facial fractures in a group of South African children and the value of computed tomography in their assessment.

The cases of 107 paediatric patients aged 0-12 years were retrospectively reviewed. The patients presented with facial trauma and both plain radiographs and computed tomography (CT) scans had been ordered. Sixty-five per cent of facial fractures were missed in radiography, but revealed on CT; fractures of the maxilla, the zygoma and the orbit were most frequently missed in radiography. Pedestrian motor vehicle accidents were the most frequent cause of facial fractures (37%), followed by passenger motor vehicle accidents (22%). In contrast with other studies reporting the mandible as the most frequent facial fracture site, the most common fracture sites in this study, in descending order of frequency, were the orbit, the frontal bone and the maxilla.

(A1) Identification of oral health care needs in children and adults, management of oral diseases.

The workshop considered five questions reviewing the identification of international oral health care needs of children and adults, and the management of oral diseases in resource-poor countries: (1) What is the role of the dental profession in the management of the HIV-infected individual? (2) Identifying health care needs-What are the epidemiology and disparities of HIV-associated oral lesions in children from different continents? (3) How effective is HIV treatment in controlling oral diseases? (4) Could we develop basic inexpensive oral and dental care protocols for economically deprived HIV-infected patients? and (5) What is the best method of arranging resources to meet the oral health care needs of people with HIV disease? The consensus of the workshop participants was that there is a need to re-target research efforts to non-established market economy countries and prioritize research in these regions to children with HIV disease. It will be important to assess commonalities and variations in oral health needs across geographical and cultural boundaries, and research efforts should be centralized in resource-poor countries to support multi-center longitudinal standardized studies. It is essential that oral health research be integrated into other health care research programs, to make these research priorities and public health initiatives feasible.

Perceptions of oral health: the South African Demographic and Health Survey of 1998.

Oral diseases are widespread in South Africa and affect large numbers of people in terms of pain, tooth loss, disfigurement, loss of function and even death. The majority of South Africans have no access to private services and are dependent on the government for oral health care services, but less than 10% of the population utilises public oral health services. This underutilisation is due to limited resources and inaccessibility. This article reports on the data collected on adults, 15 years and older, from the South African Demographic and Health Survey carried out in 1998, relating to perceptions of oral health. The questions dealt with oral health problems, utilisation of oral health services, loss of natural teeth, oral health practices and knowledge of water fluoridation. The results are discussed in terms of age, gender, education, place of residence, province and classification according to the previous population registration act. A high proportion (36%) of people had experienced oral health problems. Teeth problems were most commonly reported in the higher age groups, non-urban areas, Eastern Cape, Northern Cape and Free State, people with little education and those classified as non-urban Africans. Significant differences were found in regard to periodontal disease, tooth loss, knowledge of fluoride between groups according to age, geographic location, race and level of education. 62% of the respondents reported that they had lost some of their natural teeth and in some communities almost a third of the respondents were edentulous. In comparing the goals of the current draft national oral health policy with the findings of this survey the following implications for policy development should be noted: A higher priority needs to be given to oral health issues; Improve access by increasing primary health care facilities through the delivery of oral health care services; The high prevalence of hepatitis and HIV/AIDS infection poses a higher risk to oral health personnel and the public and The successful implementation of water fluoridation depends upon public knowledge, understanding and support.